When to Hold Xarelto (Rivaroxaban) for Colonoscopy
For diagnostic colonoscopy with or without biopsy, omit the morning dose on the day of the procedure; for therapeutic colonoscopy (polypectomy, EMR/ESD), hold rivaroxaban for 48 hours (2 days) if creatinine clearance ≥50 mL/min, or 72 hours (3 days) if creatinine clearance is 30-49 mL/min. 1, 2
Risk Stratification of Colonoscopy
Colonoscopy procedures fall into two distinct bleeding risk categories that determine management:
Low-risk procedures (diagnostic only):
- Diagnostic colonoscopy with or without mucosal biopsy 1
- These can be performed with minimal interruption of anticoagulation 1
High-risk procedures (therapeutic interventions):
- Polypectomy 1
- Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) 1
- Endoscopic dilation of colonic strictures 1
- Colonic stenting 1
Holding Rivaroxaban: Specific Timing by Renal Function
For Diagnostic Colonoscopy (Low Bleeding Risk)
Simply omit the morning dose on the day of the procedure 1. This provides adequate safety while minimizing thrombotic risk, as rivaroxaban has a half-life of 5-13 hours in patients with normal renal function 2.
- No need to hold doses the day before 1
- No bridging anticoagulation required 1, 2
- Resume usual dose the evening of the procedure if no bleeding 1
For Therapeutic Colonoscopy (High Bleeding Risk)
The timing depends critically on renal function because approximately 33% of rivaroxaban clearance is renal 2, 3:
Creatinine clearance ≥50 mL/min (normal renal function):
- Hold rivaroxaban for 48 hours (2 days) before the procedure 1, 2
- Last dose should be taken 2 days before procedure day 1
- This allows 2-3 half-lives of elimination 2
Creatinine clearance 30-49 mL/min (moderate renal impairment):
- Hold rivaroxaban for 72 hours (3 days) before the procedure 1, 2
- Last dose should be taken 3 days before procedure day 1
- Renal impairment increases rivaroxaban exposure by 1.52-fold and prolongs elimination 3
- The pharmacodynamic effect (prothrombin time prolongation) increases 2.16-fold in moderate renal impairment 3
Critical Considerations and Common Pitfalls
Do not use INR or aPTT to guide timing – rivaroxaban's effect on these tests is inconsistent and unreliable for surgical clearance 2. The timing should be based solely on renal function and elapsed time.
Assess renal function before every procedure – use the Cockcroft-Gault formula to calculate creatinine clearance 1. Acute kidney injury can markedly prolong rivaroxaban elimination 2, 4.
Do not bridge with heparin – routine bridging is not required during the 24-72 hour interruption period due to rivaroxaban's rapid offset and onset 1, 2. Bridging only increases bleeding risk without reducing thrombotic events 1.
Consider drug interactions – P-glycoprotein inhibitors and CYP3A4 inhibitors increase rivaroxaban plasma concentrations and may require longer discontinuation times 1, 4.
Resuming Rivaroxaban After Colonoscopy
For diagnostic colonoscopy:
- Resume usual dose the evening of the procedure if no bleeding 1
- Rivaroxaban achieves anticoagulation rapidly (unlike warfarin) 2
For therapeutic colonoscopy:
- Wait at least 24 hours after the procedure once adequate hemostasis is confirmed 2
- For very high bleeding risk interventions, consider a step-wise approach: 10 mg on day 1 post-procedure, 10 mg on day 2, then full dose (20 mg) on day 3 onward 2
- Do not restart the full therapeutic dose on the day of surgery (day 0), as this markedly raises bleeding risk 2